Terms Of Restenosis Research Articles

Drug-Coated Balloon Versus Drug-Eluting Stent in Patients With Femoropopliteal Artery Disease: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis, we aimed to compare drug-coated balloon (DCB) to drug-eluting stent (DES) in patients with femoropopliteal lesions in terms of restenosis, target lesion revascularization (TLR), and mortality. A comprehensive literature search was performed through PubMed, Scopus, and Embase databases. The intervention group was patients receiving percutaneous balloon angioplasty using the DCB. The control group was patients receiving percutaneous intervention using the DES. The primary outcome was restenosis, and the secondary outcomes were TLR and mortality. There were 4 studies comprising 812 patients (906 lesions) included in this systematic review and meta-analysis. The rate of restenosis was .19 [.13, .26] in DCB and .24 [.20, .28] in DES. There was a trend toward lower rate of restenosis (OR .73 [.52, 1.03], P = .074; I2: 46.3%) for DCB use compared to DES use. The rate of TLR was .11 [.08, .14] in DCB and .17 [.14, .21] in DES. TLR was lower (OR .61 [.41, .92], P = .017; I2: 1.2%) in the DCB group compared to the DES group. There were no significant differences in mortality (OR 1.38 [.78, 2.44], P = .268; I2: 0%) among the two groups. Meta-regression analysis showed that the rate of restenosis in DCB in this pooled analysis was affected by sex (reference: male, coefficient -.004, P = .009), smoking (coefficient: .003, P = .010), and total occlusion (coefficient: .008, P = .004). DCB use in patients with femoropopliteal lesion was associated with similar rate of restenosis, lower TLR, and similar mortality rate compared to DES use.

Trans-nasal endoscopic repair without stenting in bilateral congenital bony choanal atresia: Our technique

: Choanal atresia is a commonly observed congenital nasal abnormality. Incidence of choanal atresia is 1 in 7,000 live births. There are various techniques which has been described for the choanal atresia repair. Here we are sharing step by step trans-nasal technique to get good results post-operatively.: The aim of this study to explain and share the technique to treat a bony choanal atresia without any stenting in the nasal cavity of a neonate. The purpose of this study to analyse the surgical outcome of single stage bony choanal atresia repair in terms of restenosis and revision surgery. : We have described the step by step approach for the repair of bony choanal atresia without using any stent in the nasal cavity. Pre surgery evaluation and surgical steps have been explained with photograph to understand this technique better.: Bony choanal atresia can be treated without any stent placement which was the most common method for the repair of congenital choanal atresia in neonates. Clinical significance: This technique will reduce the chances of complication which arises because of stenting in the nasal cavity. This technique is simple and easily reproducible in the practise.

Numerical study of hemodynamics in a complete coronary bypass with venous and arterial grafts and different degrees of stenosis

Cardiovascular diseases are among the leading causes of death in the world. The coronary blockage is one of most common types of these diseases that in the majority of cases has been treated by bypass surgery. In the bypass surgery, a graft is implemented to alter the blocked coronary and allow the blood supply process. The hemodynamic characteristics of the bypass strongly depend on the geometry and mechanical properties of the graft. In the present study, the fluid-structure interaction (FSI) analysis is conducted to investigate the bypass performance for a thoracic artery as well as a saphenous vein graft. Blood flow introduces a pressure on the walls of the graft which behaves as a hyperelastic material. A complete coronary bypass with stenosis degrees of 70% and 100% is modeled. To consider the nonlinear stress-strain behavior of the grafts, a five parameter Mooney-Rivlin hyperplastic model is implemented for the structural analysis and blood is assumed to behave as a Newtonian fluid. The simulations are performed for a structured grid to solve the governing equations using finite element method (FEM). The results show that wall shear stress (WSS) for saphenous vein is larger than that of thoracic artery while the total deformation of the thoracic artery is larger compared to the saphenous vein. Also, for the venous grafts or lower stenosis degree, the oscillatory shear index (OSI) is higher at both left and right anastomoses meaning that venous grafts as well as lower degree of stenosis are more critical in terms of restenosis.

Comparative Effectiveness of Endovascular Treatment Modalities for De Novo Femoropopliteal Lesions: A Network Meta-analysis of Randomized Controlled Trials

Purpose: To report the results of a network meta-analysis of randomized controlled trials (RCTs) comparing multiple endovascular treatments for de novo femoropopliteal lesions. Materials and Methods: The MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched on June 1, 2019, for prospective RCTs comparing 14 treatments [ie, atherectomy, brachytherapy, cryoplasty, cutting balloons, drug-coated balloons, bare nitinol stents, drug-eluting stents (DES), covered stents (CS), and combinations] in the treatment of de novo femoropopliteal lesions. Outcomes were technical success; binary restenosis and target lesion revascularization (TLR) at 6, 12, and/or 24 months; and all-cause mortality at 12 months. Ultimately, 53 articles reporting on 45 studies (91 study arms; 5565 patients) were selected. For the technical success outcome, all types of stents, all balloons, and all atherectomy devices were aggregated in stent, balloon, and atherectomy technology groups, respectively. Results: In terms of technical success for aggregated treatment types, stent technology was the most effective treatment and was better than balloon and atherectomy technologies. In terms of binary restenosis, DES was the most effective single treatment at the 6- and 12-month follow-up and CS at the 24-month follow-up. Both DES and CS were better than the majority of other single treatments, including balloon angioplasty, cutting balloon, cryoplasty, directional atherectomy, and bare nitinol stent during all follow-up periods. In terms of TLR, DES was the second most effective single treatment and the most effective single treatment at the 6- and 12-month follow-up intervals; CS was the most effective single treatment at the 24-month follow-up. Both DES and CS were better than the majority of other single treatments. The 12-month all-cause mortality of both DES and CS were similar to other treatments, whereas cryoplasty seemed to be the least effective treatment with regard to binary restenosis and TLR. Conclusion: Both DES and CS had substantial advantages in terms of restenosis and TLR in femoropopliteal lesions and were similar to aggregate stent technology in terms of technical success. DES performed better within 12 months after operation and CS at ~24 months, but neither had much advantage in terms of mortality. In contrast, cryoplasty seemed to be a less effective treatment.

Efficacy of plaque debulking for bifurcated or ostial lesions by directional coronary atherectomy prior to second-generation drug eluting stenting.

We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) prior to second-generation drug-eluting stent (DES) implantation for bifurcated coronary lesions. Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting is used. Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-second-generation DES plaque debulking with a novel DCA catheter (ATHEROCUT®, Nipro Co., Osaka, Japan) was conducted. All patients were scheduled to perform a follow up angiography (9-12 month coronary angiography or coronary computed tomography). The primary end point was target vessel failure (TVF) at follow up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year. A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all cases without any major procedure-related event and only one case required complex stenting. The TVF rate at 9-12 month follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at the ostium of the main-branch in three cases. No death, coronary artery bypass grafting, or myocardial infarction were reported for any patients within the first year. DCA before second-generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions.

P974Efficacy of plaque debulking for bifurcated or ostial lesion by directional coronary atherectomy before 2nd generation drug eluting stent (PERFECT2)

Abstract Objectives We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions. Background Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used. Methods Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year. Results A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year. Figure1 Conclusion DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions. Acknowledgement/Funding None

Comparative Effectiveness and Safety of Polymer-Free Biolimus-Eluting Stent and Durable Polymer Everolimus-Eluting Stent in All-Comer Patients Who Underwent Percutaneous Coronary Interventions

We aim to compare Polymer-Free Biolimus-Eluting Stent (PF-BES) with Durable Polymer Everolimus-Eluting stent (DP-EES) in unselected patients. PF-BES showed a favorable profile in high-bleeding risk patients who underwent percutaneous coronary intervention. Limited data are available on PF-BES compared with second-generation durable polymer-coated drug-eluting stents in patients eligible for standard dual antiplatelet therapy. A total of 848 consecutive patients were enrolled: 306 patients were treated with PF-BES and 542 with DP-EES. Stent performance was tested in a propensity score-matched population and in a Complex Higher-Risk and Indicated Patients (CHIP) subpopulation. A per-lesion analysis on 1,204 lesions (PF-BES = 424 vs DP-EES = 780) was also performed. At a medium follow-up of 18.5 ± 5.0 months, no differences in the matched population were found in terms of major adverse cardiac events (PF-BES 9.0% vs DP-EES 4.5%; p 0.091), myocardial infarction (PF-BES 6.2% vs DP-EES 2.3%; p 0.111), stent restenosis (PF-BES 2.3% vs DP-EES 0.0%; p 0.123), definite or probable stent thrombosis (PF-BES 2.8% vs DP-EES 1.1%; p 0.448). A significant inferior rate of restenosis was observed in the DP-EES arm in the whole (PF-BES 2.3% vs DP-EES 0.6%; p 0.041) and CHIP populations (PF-BES 4.3% vs DP-EES 0.5%; p 0.023), as well as in the per-lesion analysis (DP-EES 0.4% vs PF-BES 1.7%; p 0.039). In conclusion, in a real-world cohort PF-BES performed similarly to DP-EES in terms of restenosis and stent thrombosis in the matched population. Nonetheless, in the whole and CHIP populations, as well as in the per-lesion analysis, restenosis occurrence resulted higher in the PF-BES group.

Acquired Pulmonary Vein Stenosis After Radiofrequency Ablation for Atrial Fibrillation: Single-Center Experience in Catheter Interventional Treatment

ObjectivesThe aim of the present study was to analyze and report a single-center experience with catheter interventional treatment of radiofrequency-induced pulmonary vein stenosis (PVS) following atrial fibrillation (AF) ablation. BackgroundCatheter interventional treatment of radiofrequency-induced PVS following AF ablation remains a challenging field because of a lack of randomized data and treatment guidelines. MethodsAll patients at a single center who underwent catheter interventional treatment for radiofrequency-induced PVS were retrospectively assessed. ResultsFrom January 2004 to September 2017, the total rate of PVS following interventional AF ablation was 0.78% (87 of 11,103). Thirty-nine patients with PVS were treated with 84 catheter interventions: 68 (81%) with percutaneous transluminal balloon angioplasty (PTA) and 16 (19%) with stent implantation. The distribution of stent type was 3 drug-eluting stents (19%) and 13 bare-metal stents (81%). The overall restenosis rate was 53% after PTA versus 19% after stent implantation (p = 0.007) after a median follow-up period of 6 months (interquartile range: 3 to 55 months). The total complication rate for PTA was 10% versus 13% for stenting (p = NS). ConclusionsThis study demonstrates significantly better outcomes in terms of restenosis after stent implantation versus PTA only, with comparable complication rates for these 2 options of interventional treatment of radiofrequency-induced PVS. In summary, despite the lack of randomized studies, the present data and currently available published studies seem to favor stent implantation as a first-line therapy in patients with radiofrequency-induced severe PVS.

Comparison of treatment strategies for femoro-popliteal disease: A network meta-analysis.

We sought to compare treatment strategies in a Bayesian network meta-analysis of randomized controlled trials. Peripheral artery disease (PAD) is a prevalent morbidity that is treated with various strategies. We performed a MEDLINE search for randomized studies comparing at least 2 treatment strategies, including bypass surgery, percutaneous transluminal angioplasty (PTA) balloons, stents, covered stents, drug-eluting stents (DES), and drug-coated balloons (DCB), in patients with native femoro-popliteal disease. Mixed treatment comparison model generation was performed to directly and indirectly compare the strategies in terms of restenosis and target lesion revascularization (TLR) presented as odds ratios (OR, [95% credible intervals]). Twenty-nine studies with 4,820 patients were included in the present study. PTA was the largest group with 1,900 patients, followed by DCB (n = 1,343), bare metal stents (n = 941), covered stents (n = 304), DES (n = 236), and bypass (n = 92). Mean age was 68 ± 9 years, 64% were male, 37% diabetic, and 55% smokers. Mean lesion length was 77 ± 44 mm, and 39% were total occlusions. Bayesian hierarchical random-effects model demonstrated all treatments were significantly better than, or had a trend toward superiority over, PTA, with DCB ranking well in both restenosis (OR = 0.29, [0.17-0.47]) and TLR (OR = 0.31, [0.20-0.46]). Nonetheless, none of the therapies showed superiority in terms of survival or amputations. Treatment of femoro-popliteal disease has significantly evolved in recent years, with higher rates of patency and freedom from TLR. However, the utility of these treatment strategies in terms of reduction of amputations and overall survival remains in question.

Abstract 62: Sildenafil Inhibits Neointimal Hyperplasia After Angioplasty, and Reduces Platelet Aggregation

Background: Restenosis and stent thrombosis after stent implantation are one of the devating issues in interventional cardiology. Sildenafil has shown its effect in reducing cardiac hypertrophy as well as improving erectile dysfunction through protein kinase G (PKG) activation. Some studies have demonstrated that PKG occupies a central switching role in modulating vascular smooth muscle cell (VSMC) phenotype in response to vascular injury. In this study, we investigated the effects of PKG activation by sidenafil on platelet aggregation and neointimal hyperplasia. Methods and Results: In terms of restenosis after vascular injury, sildenafil significantly reduced neointimal hyperplasia in rat carotid arteries compared to control group. This effect of sildenafil was accompanied by the reduction of viability, cell cycle progression, and migration of VSMCs. This was also confirmed in the injured arteries in vivo. Further studies showed that the increased PKG activity by sildenafil inhibited PDGF-stimulated phenotype change of VSMCs from a contractile to a synthetic form. Conversely, the use of PKG inhibitor or gene transfer of dominant-negative PKG reversed the effects of sildenafil, resulting in the increased viability of VSMCs and neointimal formation. In addition, the mice treated with sidenafil showed the facilitated re-endothelialization, compared to control group. Furthermore, we confirmed the effect of sidenafil through PKG activation using cGK-KO mice. Interestingly, sildenafil significantly inhibited platelet aggregation induced by ADP or thrombin. This effect was reversed by PKG inhibitor, suggesting that sildenafil inhibits platelet aggregation via PKG pathway. Furthermore, assays for VASP phosphorylation and P-selectin activation showed the same inhibitory effect of sildenafil on platelet activation. Conclusions: This study showed that sildenafil inhibits not only platelet aggregation, but also neointimal hyperplasia through the PKG pathway. These findings suggest that sildenafil could be a promising candidate drug of drug-eluting stents for the prevention of restenosis without other complications such as stent thrombosis.

Treatment of a Coronary Bifurcation Lesion Using One Dedicated Sirolimus Eluting Bifurcation Stent in Combination with a Bioresorbable Vascular Scaffold: A Novel Option for Coronary Bifurcation Approach.

We present a complex bifurcation lesion treated with a new two-stent strategy combining a dedicated sirolimus eluting bifurcation stent, BiOSS Lim, with a bioresorbable vascular scaffold (BVS). The advantages of this strategy compared with the conventional two-stent approach are as follows: the dedicated stent protects the carina from being damaged, the large cell at the middle zone of the BiOSS Lim gives possibility to enter easily into the side branch (SB) with any standard size conventional device, and, finally, the additional use of BVS in the SB could have a long-term benefit in terms of restenosis.

Endolaryngeal dilatation versus laryngotracheal reconstruction in the primary management of subglottic stenosis

ObjectivesThe scope of the study is to compare endolaryngeal dilatations (ED) with laryngotracheal reconstruction with cartilage grafting (LTRCG) in terms of restenosis. MethodsPediatric subglottic stenosis patients treated in Hacettepe University, between 2002 and 2012 were retrospectively evaluated. Patients who had ED or LTRCG as primary management were included in the study. EDs were grouped into bronchoscopic dilatation (BD), laser incision and balloon dilatation (LBD) and cold knife incision and balloon dilatation (CKBD). The groups were evaluated in terms of restenosis and decannulation rates. ResultsThere were 35 patients (9 females, 26 males; mean age 4.42). LTRCG was performed in 16 patients (9 anterior and 7 anterior and posterior grafts). EDs were performed in 19 patients with 6 CKBDs, 7 LBDs and 6 BDs. There were 3 grade II, 13 grade III cases in the LTRCG group while 4 grade I, 6 grade II, 8 grade 3 and 1 grade 4 in the ED group. Overall decannulation rate was 97% (34/35) in all patients. Restenosis was higher in the ED group (63.2%) than the LTRCG group (31.3%) with rates of CKBD 16.7% (1/6), LBD 71.4% (5/7) and BD 100% (6/6). Restenosis rates were found to be increasing with higher grades (grade I–25%, grade II–66%, grade III–85%). ConclusionED may need more repetitive interventions than LTRCG due to restenosis. Less restenosis might be observed when balloon is used for dilatation and cold knife for mucosal incisions.

Real Polymer-Free Sirolimus- and Probucol-Eluting Versus Biodegradable Polymer Sirolimus-Eluting Stents for Obstructive Coronary Artery Disease: DKPLUS-Wave 1, a Multicenter, Randomized, Prospective Trial

Polymer-free sirolimus- and probucol-eluting stents (Real Dual drug-eluting stents [DES]) is as effective as first-generation DES in treating coronary artery stenosis. It is unknown whether sirolimus-eluting stents containing biodegradable polymer (Excel) would be superior to real Dual DES. This study aimed to investigate the difference in target vessel revascularization (TVR) at 12 months in patients with coronary artery disease treated by the implantation of Dual DES or Excel stents. Three hundred and forty-six patients with de novo coronary artery disease were recruited from six centers in China and randomly assigned to either the Dual DES or the Excel group. The primary endpoint was the occurrence of TVR at 12 months. The secondary endpoint was angiographic in-stent restenosis and late lumen loss at 13 months. Stent thrombosis (ST) served as the safety endpoint. Dual anti-platelet therapy (DAPT) was prescribed for 6 months. Clinical follow-up for 12 months and repeat angiography at 13 months were available in 100% and >90% of patients, respectively. The ISR and in-stent late loss were significantly different between the Excel (3.1%, 0.09 ± 0.11 mm) and the Dual DES (19.5%, 0.36 ± 0.32 mm, P < 0.001, P < 0.001, respectively) groups. The TVR (3.5%) in the Excel group was significantly less than in the Dual DES group (13.9%, P = 0.001). The ST rate beyond 12 months in the Dual DES group was 0%, and this was 1.2% in the Excel group (P = 0.499). The Excel stent was statistically superior to the Dual DES in terms of restenosis, late loss, and TVR for long lesions.

Tissue coverage and neointimal hyperplasia in overlap versus nonoverlap segments of drug-eluting stents 9 to 13 months after implantation: In vivo assessment with optical coherence tomography

Histologic experimental studies have reported incomplete neointimal healing in overlapping with respect to nonoverlapping segments in drug-eluting stents (DESs), but these observations have not been confirmed in human coronary arteries hitherto. On the contrary, angiographic and optical coherence tomography studies suggest that DES overlap elicits rather an exaggerated than an incomplete neointimal reaction. Optical coherence tomography studies from 2 randomized trials including sirolimus-eluting, biolimus-eluting, everolimus-eluting, and zotarolimus-eluting stents were analyzed at 9- to 13-month follow-up. Coverage in overlapping segments was compared versus the corresponding nonoverlapping segments of the same stents, using statistical pooled analysis. Forty-two overlaps were found in 31 patients: 11 in sirolimus-eluting stents, 3 in biolimus-eluting stents, 17 in everolimus-eluting stents, and 11 in zotarolimus-eluting stents. The risk ratio of incomplete coverage was 2.35 (95% CI 1.86-2.98) in overlapping versus nonoverlapping segments. Thickness of coverage in overlaps was only 85% (95% CI 81%-90%) of the thickness in nonoverlaps. Significant heterogeneity of the effect was observed, especially pronounced in the comparison of thickness of coverage (I(2) = 90.31). The effect of overlapping DES on neointimal inhibition is markedly heterogeneous: on average, DES overlap is associated with more incomplete and thinner coverage, but in some cases, the overlap elicits an exaggerated neointimal reaction, thicker than in the corresponding nonoverlapping segments. These results might help to understand why overlapping DES is associated with worse clinical outcomes, both in terms of thrombotic phenomena and in terms of restenosis and revascularization.

Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results

The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. Operation time, shunt usage rates, hospitalization time (P < .0001), and permanent stroke rates (P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.

Our medium-term results with aortic balloon valvuloplasty and factors affecting development of aortic regurgitation

The objective of this study was to assess medium-term results of aortic balloon valvuloplasty (ABV) in congenital aortic stenosis and to determine factors affecting development of aortic regurgitation (AR). Between September 2003 and January 2010, 114 ABV procedures performed on 97 patients analyzed retrospectively. Patients were evaluated in terms of transvalvular gradients before and after procedure, development of new aortic insufficiency or increase in the current insufficiency and factors affecting the procedural success and development of aortic insufficiency. In addition, follow up results were also evaluated in terms of restenosis and increase or decrease of aortic regurgitation. Student's t-test, ANOVA for repeated measurements, linear discriminant and Kaplan-Meier survival analyses were used for statistical analysis. The mean age was 6.63±6.33 year (2 days-21 years). Mean follow-up was 32.6±25.1 months (1 to 75 months). Thirty-seven patients were infant (<1 year) and 18 of them were newborn. The peak systolic pressure gradient decreased from 77.2±24.9 mmHg to 28.5±12.9 mmHg (p=0.0001). Eighty-two procedures were optimal, 29 suboptimal and 3 were unsuccessful. AR developed in totally 53 patients, 16 of them were significant degree. Balloon /annulus ratio and the percentage of reduction in gradient was meaningfully higher in patients with significant aortic regurgitation (p=0.02 and p=0.03, respectively). Infants show more significant AR (9/37, 24%) in comparison with bigger patients (7/77, 9%) (p=0.02). Four patients died after procedure at intensive care unit, three of them were newborn. ABV is safe and effective palliative method for the treatment of congenital aortic stenosis. AR, which was the most common complication, incidence was increased in infancy and was related with high balloon/annulus ratio and high reduction in gradient.

Comparison of sirolimus-eluting and bare metal stent for treatment of patients with total coronary occlusions: results of the GISSOC II-GISE multicentre randomized trial

Percutaneous coronary intervention with bare metal stent (BMS) in chronic total coronary occlusions (CTOs) is associated with a higher rate of angiographic restenosis and reocclusion than that observed in subtotal stenoses. Preliminary reports have suggested a better performance of drug-eluting stents in CTO. In this multicentre, randomized trial, we compared the mid-term angiographic and clinical outcome of sirolimus-eluting stent (SES) or BMS implantation after successful recanalization of CTO. Patients with CTO older than 1 month, after successful recanalization, were randomized to implantation of SES (78 patients) or BMS (74 patients) in 13 Italian centres. Clopidogrel therapy was prescribed for 6 months. The primary endpoint was in-segment minimal luminal diameter (MLD) at 8-month follow-up. Secondary clinical endpoints included death, myocardial infarction (MI), target lesion revascularization (TLR), and target vessel revascularization (TVR) at 24 months. Patients treated with SES showed, at in-segment analysis, a larger MLD (1.98 +/- 0.57 vs. 0.98 +/- 0.80 mm, P < 0.001), a lower late luminal loss (-0.06 +/- 0.49 vs. 1.11 +/- 0.79 mm, P < 0.001), and lower restenosis (9.8 vs. 67.7%, P < 0.001) and reocclusion (0 vs. 17%, P = 0.001) rates. At 24-month follow-up, patients in the SES group experienced fewer major adverse cardiac events (50.0 vs. 17.6%, P < 0.001) mainly due to a lower rate of both TLR (44.9 vs. 8.1%, P < 0.001) and TVR (44.9 vs. 14.9%, P < 0.001). In CTO, SES is markedly superior to BMS in terms of restenosis and reocclusion rate, and incidence of repeat revascularization at 24 months. Clinicaltrials.gov identifier: NCT00220558.

Decreased ratio of high-molecular-weight to total adiponectin is associated with angiographic coronary atherosclerosis severity but not restenosis

Backgrounds Adiponectin is thought to protect against atherosclerosis and its expression is decreased in metabolic syndrome and diabetes mellitus. Adiponectin has a high-molecular-weight (HMW) multimer structure in the blood. We determined whether circulating HMW adiponectin, total adiponectin, or their ratio predicts baseline angiographic coronary artery disease (CAD) severity and restenosis after percutaneous coronary intervention (PCI). Methods Patients with stable angina pectoris who underwent PCI for a de novo lesion and had angiographic follow-up at our hospital were retrospectively enrolled. The study patients were grouped as moderate ( N = 68) or severe ( N = 63) coronary atherosclerosis by the baseline median Gensini severity score (moderate < 22, severe ≥ 22). Results Univariate analysis showed that subjects in the severe CAD group had a lower HMW/total adiponectin ratio (0.32 ± 0.19 vs. 0.37 ± 0.16, p = 0.024) while the absolute value of HMW adiponectin (2.17 ± 2.05 vs. 2.27 ± 2.07 µg/ml, p = 0.389) and total adiponectin (5.97 ± 3.12 vs. 5.76 ± 2.91 µg/ml, p = 0.807) were similar between the severe and moderate CAD groups. In a multivariate binary logistic regression model, a higher serum HMW/total adiponectin ratio (odds ratio 0.058, p = 0.018) was negatively, while hypercholesterolemia (OR 2.475, p = 0.029) was positively associated with coronary atherosclerosis disease severity. In terms of restenosis after PCI (mean follow-up at 12 ± 13 months), HMW adiponectin, total adiponectin and their ratio were similar between restenotic ( N = 91) and non-restenotic groups ( N = 40). Conclusions A decreased ratio of circulating HMW adiponectin to total adiponectin is associated with angiographic disease severity but not restenosis in CAD patients undergoing PCI.

Coronary artery bypass grafting versus drug-eluting stents in multivessel coronary disease. A meta-analysis on 24,268 patients☆

Coronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DES) have significantly improved results of PCI in terms of restenosis but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarizes available data from observational cohorts comparing DES-PCI versus CABG. We performed a systematic literature search for observational cohorts comparing CABG versus DES-PCI in patients with multivessel coronary disease. The mixed model method was used to obtain the pooled hazard ratio (HR) for outcomes of interest. A total of nine observational nonrandomized studies were identified and analyzed including a total of 24,268 patients with multivessel coronary disease who underwent DES-PCI (n=13,540) and CABG (n=10,728). Mean follow-up time was 20 months. Pooled analysis showed that DES-PCI and CABG were comparable in terms of composite occurrence of death, acute myocardial infarction and cerebrovascular accidents (HR=0.94; 95% CI=0.72-1.22; p=0.66). However, there was a significantly higher risk of repeat revascularization in the DES-PCI group (HR=4.06; 95% CI=2.64-6.24; p<0.001). Overall major adverse cardiac and cerebrovascular events rate in the DES-PCI was higher compared to the CABG group (HR=1.86; 95% CI=1.36-2.54; p<0.001). In the 'real world' clinical practice, overall major adverse cardiac and cerebrovascular events rate continues to be higher after DES-PCI due to an excess of redo revascularization compared with CABG.

Routine stenting vs. balloon angioplasty in ST-segment elevation myocardial infarction due to proximal left anterior descending coronary artery occlusion

Primary angioplasty has been shown to improve the outcome in selected patients with ST-segment elevation myocardial infarction. However, no data have been reported of patients with proximal left anterior descending artery occlusion. In the Zwolle-6 randomized trial, a total of 1683 consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or balloon angioplasty without any exclusion criteria. The aim of this substudy was to investigate the benefits of coronary stenting as compared to balloon angioplasty in patients with proximal left anterior descending artery occlusion. From April 1997 to October 2001, among a total of 1683 consecutive patients with ST-segment elevation myocardial infarction randomized to stenting or balloon angioplasty before the initial angiography, a total of 218 patients underwent primary angioplasty of proximal left anterior descending artery occlusion. One-year follow-up data were available from all patients. A total of 107 patients were randomized to stent and 111 patients to balloon angioplasty. The cross-over rates from balloon to stent and stent to balloon were 35.1 and 13.1%, respectively (P<0.0001). The groups were comparable in terms of postprocedural thrombolysis in myocardial infarction flow, myocardial blush grade, distal embolization, and ST-segment resolution. Stenting was associated with benefits in terms of restenosis (27.6 vs. 53.8%, P=0.03) and target vessel revascularization (15.0 vs. 24.3%, P=0.081), whereas no difference was observed in mortality (11.2 vs. 13.5%, P>0.1) and reinfarction (11.2 vs. 8.1%, P>0.1) as compared with balloon angioplasty. As compared with balloon angioplasty, routine stenting does reduce angiographic restenosis, without significant benefits in terms of death and reinfarction among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction due to proximal left anterior descending artery occlusion.